Stand with Trans, Oakland County Mental Health/ Medical Provider Questionnaire

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Stand with Trans, a 501c3 nonprofit, has received a grant to help us create a directory of transgender-affirming providers in Oakland County for transgender youth (through age 24) and their families. Participation is optional, and there will not be a negative impact if you indicate that you would not like to be on our directory or provide services to this community.

Please contact Logan@standwithtrans.org with any questions, comments, or concerns. Thank you for taking the time to complete this questionnaire!

Email *

We will have two directories--one is public facing, and will exist on Stand with Trans' Lifeline Library. Given the current political climate, we understand that some providers may not be comfortable being publicly listed. The other directory will be an internal-use-only document for Stand with Trans staff who are assisting community members with recommendations.

If you consent to being listed in one of the directories, please fill out the following questions about your practice.

I consent to being listed in the public-facing Lifeline Library and the internal directory

I consent to only being listed in the internal directory

I do not consent to being listed in either directory/ do not wish to participate

What is your name? *

I am a licensed... *

Therapist or Social Worker

Counselor

Psychologist

Psychiatrist

Psychiatric Nurse Practitioner

Primary Care Provider (Physician)

Primary Care Provider (Nurse Practitioner or Physician's Assistant)

Pediatrician

Endocrinologist

Gynecologist

Urologist

Reproductive Specialist

Surgeon (please specify in "Other")

Speech-Language Pathologist/ Vocal Coach

I don't see my specialty listed (please specify in "Other")

Other:

Required

Is your practice located in Oakland County, MI? *

Yes

Do you feel comfortable serving transgender patients and their families? *

Yes, I am comfortable with that

Maybe, I don't feel that I am fully prepared to serve that population at this time, but I'd like to

No, I have a religious or other objection to serving that population

Other:

If you are comfortable serving transgender patients and their families, what age ranges are you able to serve? *

0-6 years old

6-12 years old

12-16 years old

16-18 years old

18-24 years old

24+ years old

Required

Please select the services you are comfortable providing to eligible patients/ patients for whom this care would be appropriate: *

I offer gender affirming medical care and/or letters for gender transition-related care

I offer transgender-informed medical care, but not medical care specific to gender transition

I offer gender affirming therapy and letters for gender transition-related care

I offer transgender-informed therapy, but not a letter for gender transition-related care

I do not offer any of these options

Other:

Required

What kind of experience do you have with the transgender community? *

I am WPATH certified

I have received some WPATH training

I have completed 1-3 continuing education (CE) opportunities about this topic

I have completed more than 3 continuing education (CE) opportunities about this topic

I have attended 1-3 informal trainings about this topic

I have attended more than 3 informal trainings about this topic

I (or someone very close to me) have lived experience as a transgender person

I have treated, or currently treat, patients who are transgender

I do not have any experience with the transgender community

Other:

Required

Do you accept Medicaid? *

Yes

Please list the insurances you accept: *

What is the name of your practice? *

What is the best email address for people to reach your practice? *

What is the best phone number for people to reach your practice? *

Office Address Line 1: *

Office Address Line 2:

Office City: *

Office Zip Code: *

Is there anything else that you think we should know? (Languages available, telehealth availability, informed consent availability for folks over 18, elaborating on an earlier answer, etc.)

Send me a copy of my responses.

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